HEDIS Compliance: Why and How Exceeding HEDIS Measures is Vital for Your Practice

HEDIS compliance

In an ever-growing healthcare market, constantly updated regulations can create a challenge for practitioners to keep up with the latest standards in providing high-quality care to patients. 

In order to better regulate both insurance plan and patient needs, the Centers for Medicare and Medicaid Services (CMS) implemented HEDIS. Initially released in 1991, HEDIS has become a necessary tool to oversee healthcare in the United States and has evolved into an integral consideration for practices across the nation.


What exactly is HEDIS?

The Health Effectiveness Data and Information Set, or HEDIS, is a set of standardized performance measures managed by the NCQA (National Committee for Quality Assurance) to evaluate insured patients’ quality of care and services. 

The Centers for Medicare and Medicaid Services, which contracted the NCQA, created a five-star quality rating system to gauge how well providers and health plans deliver care, with a rating of five being excellent and one being poor. HEDIS also measures the effectiveness of Special Needs Plans (SNPs), including common public health issues like asthma, cancer, heart disease, diabetes, and more. 

HEDIS assesses the quality of healthcare plans based on over 90 measures across six domains of care: 

  • Effectiveness
  • Availability
  • Experience
  • Utilization/ Risk-Adjusted Utilization
  • Health plan descriptive information
  • Measures reported using electronic clinical data systems. 

These measures allow HEDIS to evaluate quality of services, compare performance from plan to plan, and make adjustments based on identified areas of improvement. 

As of now, 90% of Medicare, Medicaid, and commercial health plans in the US participate in HEDIS review by submitting medical records, administrative data, and other supplemental information. By reviewing medical data, HEDIS employers are able to build a picture of how healthcare plans and practices are working with patients to reach benchmarks specific to their conditions. Understanding how and why benchmarks are met results in comprehensive records documenting what is effective and what is not when it comes to special needs healthcare. 



HEDIS’ primary purpose lies in improving preventative care. Better preventative care programs mean patients require fewer doctors visits and experience thorough care when they do visit their care providers.

In order to reap the benefits of these preventative efforts, however, both insurance plans and healthcare providers should strive to achieve HEDIS compliance in all six domains.

HEDIS encourages these efforts by providing pay-for-performance incentives to participating organizations. CMS defines these incentives as “The use of payment methods and other incentives to encourage quality improvement and patient-focused high-value care.”


HEDIS for Comprehensive Diabetic Care

In 2021, 37.3 million people in the United States had diabetes, with 8.5 million undiagnosed. 

Furthermore, of US adults aged 18 or older, 96 million were diagnosed with pre-diabetes, equalling 38% of the adult population. 

The prevalence of diabetes in the United States is evident, though its harmful side effects are often understated. Diabetes complications can result in anemia, kidney disease, high blood pressure, and diabetic retinopathy, with the lattermost, often leading to blindness if it isn’t diagnosed and treated early on.

HEDIS seeks to prevent the onset of these related illnesses through careful monitoring, typically performed during yearly exams.

HEDIS’ comprehensive diabetic care measures assess US adult diabetics ages 18-75 who completed each of the following: hemoglobin A1c testing, retinal eye exam, nephropathy (kidney disease monitoring), and blood pressure control. 

These comprehensive diabetic care benchmarks seek to minimize diabetes-related complications. However, several factors can play into an organization’s HEDIS compliance scores, including easy access to testing for patients, the effectiveness of the testing itself, and a patient’s care experience with their primary medical physician. 


HEDIS Measures for Diabetic Retinopathy

Diabetic Retinopathy (DR), a complication of diabetes, is characterized by damage to the small blood vessels present in the retina, usually due to high blood sugar levels. DR can come in two main stages: non-proliferative DR, which can cause slight blurring of vision or proliferative DR, which can lead to complete vision loss. 

4.2 million adults were diagnosed with DR in the US alone, with around 655,000 individuals having vision-threatening DR. Moreover, diabetes-related complications are now the leading cause of blindness among adults aged 18-64 years of age. 

Despite these harrowing statistics, blindness resulting from diabetic retinopathy is entirely preventable with careful disease monitoring during yearly retinal exams. In order to meet HEDIS compliance measures for comprehensive diabetic care, patients must complete a retinal eye exam in the current year by an eye care professional; i.e., an ophthalmologist or optometrist, which can include remote interpretation solutions suited for point-of-care implementations. 

Still, often appointments with specialists and referrals can make completing yearly retinal exams hard-to-commit to and inaccessible for a vast amount of patients. Whether it be work, proximity to an eyecare specialist, inability to find childcare, or the mistaken belief that yearly retinopathy exams aren’t necessary—  busy, working patients may struggle to find the time to attend follow-up appointments. When patients begin to underestimate the importance of DR exams, they begin neglecting their diabetic care— which is where tools like IRIS come in, to make yearly retinal exams easy on patients with a lot on their plate.


IRIS For HEDIS Compliance

The IRIS solution makes meeting HEDIS requirements easy by making retinal exams convenient for patients and care providers.

IRIS works with a number of different brands of fundus cameras to ensure flexibility and ease in adoption. This will allow for your team to have a smooth integration of IRIS technology into existing workflows, allowing for downtime and training to be minimal. We help healthcare offices take into account the right considerations when implementing retinal exams into their care offerings. Important factors for success include your organization’s space constraints and workflow. 

In addition, the IRIS solution is extremely user friendly, making it simple to train office staff in how to perform these diabetic retinopathy exams. In turn, this ease of examadministration increases accessibility for patients who previously faced barriers., allowing patients to complete their yearly exams in non-eyecare specific settings. It is a win-win approach for both patients and practices— quality care is easily administered to patients while practices meet HEDIS requirements and receive financial compensation for doing so. 

After IRIS-trained staff perform a retinal exam, imaging results are uploaded directly to the IRIS cloud, where our proprietary image enhancing software optimizes the likelihood that these images can be interpreted. These higher-quality images allow our IRIS Reading Center (IRC) board-certified eye care professionals, to accurately review and diagnose the presence of diabetic retinopathy or glaucoma , as well as its severity. These providers can also document the suspicion of many other retinal  diseases commonly found in diabetic patients, such as macular edema , cataracts, wet and dry AMD, and others. 

IRIS technology increases ease of access to retinal exams for patients, encouraging greater willingness to complete them and, in turn, improves your practice’s HEDIS compliance measures.


Is IRIS Right For You?

According to the CDC, more than one in ten Americans have diabetes, making quality diabetic care top-of-mind for most practices.

The American Diabetes Association (ADA), in response to these recent CDC figures, stated, “[the data] show an alarming increase of diabetes in our nation among young adults,” while the high number of unknown pre-diabetics “is fueling the diabetes epidemic.” 

Diabetes is one of the most prevalent health issues in the United States, and as the diabetic population grows, undiagnosed cases of diabetic retinopathy continue to threaten the vision of adults across the country.

Healthcare compliance software is a fantastic way to combat this growth, hold healthcare providers accountable, and ensure your organization receives high HEDIS scores.

Diabetic Retinopathy exams are necessary for all PCP (primary care providers) and healthcare organizations. To avoid progression of DR past the point of treatability, all patients with diabetes and pre-diabetes should be receiving yearly retinal examinations, however only 40-50% of the diabetic population follow through with them annually. 

DR exams are necessary to monitor the health of diabetic patients. As one of the primary HEDIS compliance measures for comprehensive diabetic care, your practice should strive to ensure that all diabetic patients complete their annual retinal exams. 

IRIS allows practices to do just that by implementing diabetic retinal examinations so as to eliminate the need for patients to book follow-up appointments or travel to see specialists. In addition, IRIS professionals provide comprehensive exam results quickly, allowing your practice to easily reach HEDIS standards while providing better quality, convenient care for your patient population.

Still, it is crucial to know how IRIS can fit into your organization. Use our return on investment calculator here to understand how IRIS can benefit your practice.

As you seek solutions to improve your practice’s HEDIS compliance ratings, reach out to us for more information on how IRIS can be integrated into your organization to work towards all-inclusive and successful diabetic care.


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